Dissociative disorders include a wide variety of syndromes whose common core is an alteration in consciousness that affects memory and identity. The essential feature of dissociative disorders is a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment. The disturbance may be sudden or gradual, transient or chronic (APA, 2013). The current diagnostic categories for dissociative disorders developed from nosological systems based on the hysteria concept, not on modern research showing a robust relationship between dissociation and trauma which occur after signiﬁcant adverse life experiences (Schore, 2001).

1) Dissociative amnesia – It is characterized by an inability to remember personal information in such a way that cannot be due to forgetfulness.
2) Dissociative identity disorder – This is the most common disorder in some countries and it is characterized by more than one identity present in one person. In the 1st case, known as the case of Eva, she had 3 personalities at a time.
3) Depersonalization/derealisation disorder – Characterized by a feeling that objects in the environment are changing shape or size or that people are automated; feeling detached from one’s body.
4) Other dissociative disorder not specified – A dissociative disorder that does not fall within the other three types of dissociative disorders.
Psychological stress refers to the emotional and physiological reactions experienced when an individual confronts a situation in which the demands go beyond their coping resources. These are the daily hassles faced by everyone in life. These include such conditions as; death of a loved one, loss of finances, separation from partner, loss of job, marital life not satisfactory etc.

Material and methods

The study was devised with the aim to study the role of stressful life events in the clinical phenomenology of dissociative disorders. A group of 40 patients diagnosed with dissociative disorders were recruited from OPD, Department of Psychiatry, Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak on the basis of consecutive sampling and 40 healthy participants which served as control group were recruited from the community by using the snow ball sampling technique. The study took place between February 2014 and October 2014.
Those patients who met a primary diagnosis of dissociative disorder according to ICD-10 (1992) criteria and ages ranged between 18 and 65 years, have been included in the study. In addition, the presence of major co-morbid medical, neurological and psychiatric illness has been excluded. With a similar age range; a group of 40 healthy community dwellers formed the control group for the study.
To identify psychological distress among healthy controls was the General Health Questionnaire-12 was used to assess them. The cut off for the questionnaire is 3 (Goldberg & Williams, 1988).
The Presumptive Stressful Life Event Scale: The scale consists of 51 life events commonly experienced by a normal Indian adult population which are arranged in a decreasing order of stress perceived. The scale has been standardized for two periods of time – lifetime and during the previous year. It is easy to administer and assessment is done by marking if the particular life event is present or absent and scoring is done by adding the assigned scores to each item. Psychological stress could be assessed by utilizing the PSLE scale. For content validation, the authors found all the coefficient of correlations ranged from 0.65 to 0.98 (Singh, Kaur & Kaur, 1984).
Multidimensional Inventory of Dissociation (MID): It is a multi-scale diagnostic instrument having a total of 218 items that is designed to comprehensively assess the entire domain of dissociative phenomena. The MID uses an 11-point Likert scale format that is anchored by Never and Always, and takes approximately 30 to 90 minutes to complete. This scale has two scoring systems: mean scores and severe dissociation score. Mean score ranges between 0 and 100. A score of 30 and above is considered a cut off mark indicative of probable dissociative psychopathology, whereas a score of 10 and below is considered an indication of a low level of dissociation. Internal reliability by Cronbach alpha value of 0.99 and Convergent validity, is 0.94 with the Dissociative Experiences Scale (Dell, 2011).

The results have shown that the age range of the clinical sample is varied from 38 years to 18 years and the healthy control range is from 19 years to 41 years. In the education category for clinical and normal participants, 12% to 20% have no formal education, 25% to 18% have received primary education, 48% to 38% had a secondary level of education and 15% to 25% were graduates. In the total sample, 45% participants belong to a joint family and 55% from a nuclear family. In the sample, 20% were males and 80% were females. In the clinical sample, 32.5% were unmarried and 67.5% were married, whereas in the normal sample, 42.5% were unmarried and 57.5% were married. In the occupation domain 57.5% to 40% were housewives, 7.5% unemployed, 22.5% students, and 12.5% to 30% employed. In the clinical sample, 70% have a rural background and 30% from urban backgrounds, whereas in normal sample, 92.5% were from a rural area and 7.5% from an urban area. In the religion category, 95% were Hindu, 2.5% Muslim and 2.5% were Sikh, whereas in the normal sample 100% belonged to the Hindu religion.

The results of the study showed that there is a significant difference between the clinical sample and the normal control in the area of psychological stress during the previous year (t=2.85, p value=0.005), and lifetime (t=2.92, p value=0.006). The clinical sample had higher stress in the sub-part of Courtship and Cohabitation psychological stress (t=1.96, p value=0.002), education (t=1.20, p value=0.05), Family and Social (t=0.79, p value=0.02), Health (t=4.63, p value=0.03), Marital and Sexual (t=1.02, p value=0.05), Legal (t=3.94, p value=0.000), Work (t=0.48, p value=0.03).

In the table 3, it has been depicted that psychological stress has been significantly related to dissociative psychopathology in all three areas; previous year, lifetime, and all domains of health.

Table 4
Regression analysis of the sample

In the analysis of regression it has been found that lifetime stresses is highly significant related to dissociative pathology (R=0.23, p value=0.000).

Discussion

There is a tremendous increase in the stressful life events which may be the main causative factor for the dissociative disorder. In the present study the results revealed the Mean and Standard Deviation of the age found (18-42). In the sample, most of the dissociative disorder diagnoses were received in middle adulthood. In the education domain participants had varied in education from illiterate to graduates in both groups and in clinical group it was found that most of the patients either had no formal education or education up to secondary level. In the sample only eight males were diagnosed with a dissociative disorder. Similar to this study a previous study also showed a higher number of married females suffering from this disorder in comparison to the male subjects (Maqsood, Akram & Ali, 2010). The seemingly dominance of dissociative disorders in women may also depend on the socio-cultural context, because men with dissociative disorders usually do not enter the general health system, but rather the legal system, i.e. they can be found in jail or forensic institutions (Spitzer & Freyberger, 2008).
In the present study, the onset of illness was found to be in their early 20s and the duration of the illness was chronic and episodic in nature. Participants’ employment status ranged from permanent job, unemployed, housewife and student. In both groups most of the females were housewives. 55% of families were found to be nuclear and 45% were joint families, showing that the subjects in the major group belong to a nuclear family. In the support of our study another study also showed similar results such as; most of the patients (62.5%) were below the age of 25 years, out of which most were female (90.4%), 67.5% belonged to a joint family, and 62.1% were from rural areas. Psychosocial stressors were clearly identified in 87.5% of the patients. The stressors were disturbed relation with in-laws (20.8%), failure in examinations or study problems (20%), disturbed relation with spouse (15.4%), husband staying abroad (13.3%), love problems (11.2%), job stress or more work-load (11.2%), relationship problem with family members or parents (9.6%), pampered child (3.3%), demands of marriage (3.3%), marriage against will (2.9%), death of a close family member (2.1%), physical illness (2.1%), demands of going abroad (1.7%), issueless (1.7%) and financial crisis (1.2%) (Roy, Roy, & Begum, et. al., 2014).
In our study results show that the total score of stressful life events in the previous year or in the past was found to be significantly higher in the clinical group than the normal group. A recent study supports these results as it was found that stressors were clearly identified in (90%) participants and ranged from disturbed relations with in-laws, engagement/marriage against wishes, disturbed relations with spouse, husband staying abroad, conflict with parents, conflict at work, failure in exam/study problem, love problems, death of spouse, and threat to life (Anuradha, Srivastava & Srivstava, 2011). Another study in which the result was found that dissociation is a protective activation of altered states of consciousness in reaction to overwhelming psychological trauma. Dissociative fugue is a rarely reported disorder. It is one of the most fascinating disorders in psychiatry (Chaturvedi, Desai & Shaligram, 2010). In contrast, the results of our study was found in a recent study in which the comparison was done between post traumatic disorder and dissociative disorder with stressful life events in which they found that significant differences among the groups in the rates of PTSD (27%, 15%, and 26%, respectively), but no differences were found in dissociation. A significant relationship was found between PTSD symptoms and cumulative trauma among the three groups, but no such relationship was found between dissociation and cumulative trauma (Finklestein & Solomon, 2009).
Our study shows that where descriptive analysis was done in the domains of Presumptive Stressful Life Events scale (family and social, financial, work, marital and sexual, health, education, legal, courtship and cohabitation and bereavement), the results showed that the clinical group had higher scores in health, family and financial, work, marital and sexual, courtship and cohabitation, education and bereavement. Out of all the domains, both the clinical and the normal group had significantly higher scores in the family and social, compared to the other domains. It means that family and social both have a significant role in life and those influencing the life. In another study that supports the results of this study, the results showed an increase in the degree of dissociative experiences in patients with a history of sexual abuse, physical abuse, neglect and stressful life events. With the exception of life events, a moderate form of traumatic experience had the same effect on dissociative experiences as severe forms. The strongest effect was found for emotional neglect, which seems to be an important pathogenic risk factor (Brewin & Saunders, 2011).
Our study also found that both the clinical as well as the normal population have significant relationships with stressful life events and dissociative experiences. There is support of these findings in literature stating that the normal population also has dissociative experiences in their life which are triggered by stressful life events. In support of our results, results of a study show that individual differences in dissociation (DIS) in undergraduates are positively related to differences in self-reported stressful or traumatic experiences in youth. In Study 1, 309 undergraduates completed a childhood stress inventory and a Dissociative Experiences Scale (DES). Differences in the degree of stress or unpredictable physical violence experienced in childhood or early adolescence were related to scores on the DES. Study 2, with 337 undergraduates, replicated these relationships and extended them to another DIS measure. Both DIS measures correlate positively with reported physical and psychological abuse (Santonastaso, Favaro, Olivotto & Friederici, 1997). Another study reports descriptive statistics and the factor analytic structure of this data. College age individuals report a variety of dissociative processes. Although the two instruments used were somewhat different in original conception, they were significantly correlated and describe similar experiences, especially in terms of the first three factors. Overall, the DES produced four factors which, in order of variance explained, are: (1) absorption/derealization; (2) depersonalization; (3) segment amnesia; (4) in situ amnesia. The QED produced five factors which were: 1) depersonalization; (2) process amnesia; (3) fantasy/daydream; (4) dissociated body behavior; and (5) trance. Overall results are discussed in terms of types of dissociative processes, implications for normal populations, and suggestions for future research (Young, D. A., Shumway, M., Flentje, A., & Riley, E. D., 2017). In a recent study also it has been found that severe dissociation was significantly associated with recent physical violence and sexual violence along with childhood sexual abuse (Kong, Kang, & Kim et. al., 2018).

Conclusion

The present study was carried out with the aim and objective to assess the stressful life events in patients with dissociative disorders and to compare the stressful life events between patients with dissociative disorders and normal controls. The majority of the sample in the study come from a rural background, a nuclear family, are housewives and the age of onset was found at 20 years. The major group was married, and education was found at the12th standard. A significant difference was found between both groups on the Presumptive Stressful Life Events Scale and both groups have higher scores stressful life events occurring in the previous year. Significant findings were that both groups have higher scores on the family and social domain in the Presumptive Stressful Life Events Scale. The results of the study showed that there is a significant relationship between stressful life events and multidimensional dissociative disorders. Our study assesses these findings in an Indian context. In addition, this is a group at risk, because many people in India, who have trances and possession, do not take treatment. Another study also found that emotional abuse, physical abuse, and physical neglect during childhood cause dissociation in later life.

Strengths and Limitations

An objective tool to assess stress has been used and MID was used to assess phenomenology of dissociation. Consecutive sampling method was employed for the recruitment of the clinical group. A structured diagnostic tool has not been used to confirm the diagnoses. A Dissociative severity assessment could have increased the strength of the study. The Study was cross sectional in nature. The effect of education was not a control. The sample size was also small. The age of the participants were also varied in range.Future directions of this study can be done on a larger sample and preventive strategies in the form of early assessment and intervention for possible problem areas would definitely be helpful.